the prib procedure - podiatry m · reputable reverdin-isham and bosch procedures led to this...

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behind modifying the Reverdin-Ish-am and Bosch procedures is aimed at bringing about a MIS osteotomy which can achieve what these tech-

niques accomplish with the added advantage of combining their inher-ent strengths.

Similarities and Differences to the Reverdin-Isham and the Bosch For patients who have IM angles under 16°, the author employs the Rever-din-Isham procedure which is performed intra-capsular in the metaphyseal area of the first metatarsal head. This procedure removes the medial bunion. A wedge osteotomy is performed angled away from the ses-amoids leaving the lateral cortex intact. The author has achieved good results with this osteotomy with IM an-gles up to 16 (Figure 2). In patients who require further reduction of the in-termetatarsal angle, utilizing a through and through vari-ation of the Reverdin-Isham leads to shortening of the first ray (Figure 3). This is obvi-ously advantageous or not depending on the patient’s foot type and deformity. For

Introduction Hallux valgus surgical correction is a common task performed by foot surgeons and is one of the more chal-lenging ones. More than 150 surgical procedures have been developed to correct HAV.1 In this presentation, the author presents a unique min-imally invasive technique (MIS) which allows for: 1) Correction of IM angles over 16° 2) Direct PASA adjustment 3) Hallux abductus rectification 4) 1st ray length preservation 5) Reduction of medial shelf cre-ated by the osteotomy 6) Removal of the medial Bunion prominence 7) Fixation options 8) An office-based para-digm 9 ) An i n expen s i v e cost-effective process 10 ) Qu i ck su rg i c a l times/10-15 minutes

Previous MIS bunion techniques offer resolution to many of the above char-acteristics and the procedure described here borrows from previous contributions. Com-bining the properties of the reputable Reverdin-Isham and Bosch procedures led to this presentation.2,3 The pro-cedure is introduced as the PRIB procedure and is the acronym for Peacock, Rever-din, Isham, Bosch.

Background Distal first metatarsal osteotomies are widely ac-cepted for treating HAV de-formities.4 These osteotomies

lend themselves well to MIS tech-niques.5 On the other hand, short-ening is observed when performing through and through osteotomies by

means of a burr.6 MIS cutting burrs have a width of 2mm and contribute to this observable fact (Figure 1). The effect is more pronounced in patients with higher IM angles.6 The rationale

Here’s a modern MIS technique for HAV correction.

The PRIB Procedure

BY DONALD PEACOCK, DPM

NEW CONCEPTS IN PODIATRIC SURGERY

The PRIB procedure is the acronym for Peacock, Reverdin, Isham, Bosch.

Continued on page 120

Figure 1: Isham Burr demonstrating 2mm width

Figure 2: Reverdin-Isham Bunionecotomy pre-op and 6 weeks post-op IM angle of 12

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2) The first metatarsal phalangeal joint can be congruent, deviated, or subluxed. 3) The intermetatarsal angle is over 16°. 4) The PASA is increased.

5) DASA angle is normal. 6) HA angles are s l ight ly or highly abnormal. 7) The relative metatarsal protru-sion angle is either positive or negative.

Operative Technique The PRIB pro-cedure combines several minimal-

example, in a patient with concurrent hallux rigidus, decompression by shorten-ing is favorable. Converse-ly, a patient with a relatively short 1st ray will not benefit from further shortening. The Bosch procedure is performed extra-capsular in the distal diaphyseal area of the 1st metatarsal and al-lows for correction of large IM angles. It does not allow for reduction of the medial bunion prominence or the cortical shelf created by the transposition of the osteot-omy. The author employs the Bosch technique to correct high IM angles in patients with minimal bunion prominence and slight PASA needs. The Bosch is not as effective in patients with large bunion promi-nences and does not allow for direct PASA correction. The Bosch proce-dure is time-efficient and is executed in five minutes. The fixation method

for the Bosch is painful for some pa-tients (Figure 4). Like the Reverdin-Isham proce-dure, the PRIB procedure allows for direct correction of PASA and re-moval of the medial bunion. Like the Bosch, the PRIB osteotomy is performed extra-capsular in the dis-tal diaphyseal area and has the same

ability to correct larger IM angles.

Pre-operative Criteria The PRIB procedure is directed at treating symp-tomatic large medial bunion deformities with IM angles over 16 degrees. The specif-ic criteria for the PRIB pro-cedure are as follows: 1) The first metatarsal phalangeal joint should have good range of motion with no crepitus or pain.

PRIB (from page 119)

Figure 4: Example of the Bosch Procedure Immediate post-op and 6 weeks post-op

Figure 6: 3.1 Burr displaying medial bunion resection

Figure 5: Percutaneous Incision with 64 blade

Figure 3: Shortening of 1st Ray following through and through Reverdin-Isham with IM angle of 21

Figure 8: Fluoroscopy view showing removal of medial eminence.

Continued on page 122Figure 7: Medial eminence eliminated as bone paste


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plished using a straight Isham burr (Figure 9). The osteotomy is angled at a 35°-45 from dorsal distal to plan-tar proximal and is angled distally to help maintain length of the first metatarsal in patients with a relative-ly short 1st ray (Figure 10). It can be made parallel to the 2nd metatarsal or proximal, if desired. The final cut of the osteotomy involves completing the lateral cortex cut with a J stroke movement leaving a lateral plantar shelf. This maneuver will allow for further 1st ray lengthening and added stability for patients requiring plantar flexion of the 1st ray (Figures 11, 12, 13). The osteotomy is then shifted by inserting a Locke elevator through the incision site into the medullary canal of the 1st ray and using this as a fulcrum to transpose the osteotomy (Figures 14, 15). After laterally shift-ing the osteotomy, a percutaneous lateral release is done (Figure 16). Thumb pressure can transpose the osteotomy in some patients. Note the plantar lateral shelf in Figure 15.

ly invasive surgical techniques. The tech-nique involves exos-tectomy of the dorsal medial aspect of the first metatarsal head, distal diaphyseal os-teotomy via a mod-ified J stroke Rever-din-Isham, transposi-tion of the metatar-sal head, reduction of the medial shelf created by the oste-otomy, percutaneous fixation, and finally a MIS Akin pha-langeal osteotomy.2,7

Minimally Invasive Technique A percutaneous punch incision

is performed with a 64 blade and is made over the plantar medial border of the first ray where the metatarsal head fans out in the distal diaphy-seal area (Figure 5). The incision is continued down in a single cut until reaching the periosteum. From this position, the 64 blade is used to un-derscore the capsule at the first meta-

tarsal phalangeal joint, employing a sweeping motion. Under fluorosco-py, a 3.1 wedge burr is inserted and the medial

prominence is resected from the first metatarsal head (Figure 6). Pressure is applied to the first metatarsal pha-langeal joint area, and the medial eminence is eliminated as bone paste (Figures 7, 8). The first step of the osteotomy involves a wedge osteotomy in the distal diaphyseal area of the first metatarsal, leaving the lateral portion of the cortex intact. This is accom-


Figure 11: J stroke lateral cortex view of the osteotomy.

Figure 13: Fluoroscopy view of initial osteotomy.

Figure 12: Flouroscopy view showing angle of osteotomy medial to lateral.

Figure 9: Wedge osteotomy in the distal diaphyseal. Figure 10: Osteotomy angled from 35-45 degrees from dorsal distal to plantar proximal.


The PRIB procedure combines several minimally invasive

surgical techniques.

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the usual sterile manner. The hand piece used with the burrs requires a high torque low speed motor. The surgeon will need to adhere to all standards required for any surgical procedure, in-cluding gentle handling of soft tissue and bone. The speed of the burr requires low RPMs so that necrosis and heating of the bone and soft tissue will not occur excessively. An ankle block is used with no tourniquet to help flush out debris and facil-itate cooling of the tissue. Proper knowledge of MIS techniques is

a prerequisite and will require mastering with less ad-vanced procedures before attempting the PRIB technique.

Post-operative Management The patient is placed in a surgical shoe and is dis-charged following the surgery. The patient is allowed to weight-bear as tolerated, and to refrain from ex-cessive ambulation including weight-bearing exercise. Post-operative pain is managed by minimal amounts

Subsequent to displacing the osteotomy, fixation is accom-plished via percutaneous K-wire placement in a modified Bosch version (Figure 17). This fixation technique permits torqueing to further close the PASA correc-tion. Percutaneous fixation can also be performed proximal dor-sal to plantar distal, if desired (Figure 18). The modified Bosch fixation and the dorsal percuta-neous fixation methods are less painful than the originally de-scribed Bosch fixation. The osteotomy can be plantar-flexed by distracting the distal fragment and pressing the medullary portion of the fragment on to the plantar later-al shelf created by the osteotomy (Figure 19). Following the fixation, the medial shelf created by the osteotomy is reduced using the same plantar medial incision, and a short Isham burr and a small rasp. Most patients will require a MIS Akin osteotomy to further correct the defor-mity.2,7

All steps of the procedure should be directly mon-itored under fluoroscopy guidance to ensure correct placement of in-cisions, osteot-omy angles, ap-propriate IM clo-sure, proper fix-ation placement, and adequate bunion promi-nence removal, etc. The proce-dure should be performed in a sterile environ-ment, with the patient prepped and draped in




Figure 14: Locke elevator inserted into medullary canal.

Figure 15: Fluoroscopy view of locke elevator inserted into medullary canal.

Figure 16: Lateral release performed under fluoroscopy.


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and to gradually progress to casual wear, as tolerated (Figure 21).

Advantages of PRIB The advantage of this MIS os-teotomy is that it allows for correc-tion of large intermetatarsal angles over 16, and can directly address PASA while limiting shortening seen with through and through os-teotomies. Also, by creating the plantar lateral shelf, added stability is gained with patients demanding plantar flexion of the first ray. In addition, the PRIB allows for reduc-tion of the medial bunion, as well as reduction of the medial shelf cre-ated by the osteotomy. Finally, fix-ation via percutaneous methods is easily achieved due to the oblique nature of the osteotomy.

Disadvantages of PRIB The most obvious disadvantage of this osteotomy is its more prox-

of pain medication and NSAIDs in suitable patients. The initial dress-ing is changed in three days. The second post-operative visit is at day 10, and the sutures are removed. Post-operative x-rays are taken in three to four weeks, and the K-wire is removed. Some minimal boney callus formation may be seen in the

x-ray at this time. The patient is al-lowed to wear an athletic shoe when the K-wire is removed. After the K-wire is removed the patients will apply their dressing as discussed below. The patient can resume all normal activities including exercise in six to eight weeks. Normal foot-gear can be worn as tolerated after four weeks.

Post-operative Bandaging It is important to properly splint the foot in a corrected position. The Akin procedure is not fixated and will re-quire external splinting via the bandage. The post-operative dress-ings are composed of two phases. The initial phase involves a sturdy com-pressive bandage. The first layer of dressing is an Unna boot ap-plied directly to the skin. This dressing allows for rectus ban-daging and splinting of the Akin osteotomy. This phase of dressing is used for immediate post-op and continues for three to four weeks with weekly bandage changes (Figure 20). The second phase of splinting involves the patient applying a toe wedge between the hallux and second toe and utilizing Coban to compress the foot. Bathing is not al-lowed until the K-wire is removed. The patient is allowed to go back into larger, athletic footgear in four weeks



Figure18: Fluoroscopy view showing proximal dorsal to plantar distal K-wire fixation.

Figure 20: Immediate post-op compressive ban-dage using an Unna boot splint.

Figure 21: 2nd phase bandage performed by pa-tient utilizing toe wedge and Coban.

Figure 17: Modified Bosch K-wire fixation.

Figure19: Osteotomy plantarflexed by distracting the distal fragment and pressing it on the lateral shelf.


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3 Bosch P, Wanke S, Legenstein R. Hallux valgus correction by method of the Bosch: A new method 7-10 year follow-up Foot Ankle Clin 2000; 5: 485-98. 4 Austin DW, Leventen EO. A new osteotomy for hallux valgus: a horizontally V displacement osteotomy etc. Clini Ortho 1981;157:25-30. 5 Schilero J: Minimal incision podiatric surgery. Principals and applications. J Am podiatry Med Assoc 75(11): 586-574, 1985. 6 Z lo to f f H : Shortening of the f i r s t meta tarsa l following osteot-omy and its clini-cal significance. J AM Podiatr Assoc 67(6) : 412 -426 , 1977. 7 A k i n O F . The treatment of HAV-New oper-ative technique. M e d S e n t i n a l 1925;33:678.

imal placement than standard distal osteotomies, such as the Austin, etc. This characteristic will result in a less stable osteotomy, requiring fixation.

Conclusion The PRIB technique borrows from already estab-lished MIS osteotomies, including the Reverdin-Isham and Bosch techniques. The procedure can be per-formed under local anesthetic in the office setting, and the technique can be performed in 10-15 minutes. The PRIB is usually done in conjunction with an Akin osteotomy. Other than the fluoroscopy, no special equipment is needed and the cost of the K-wire is not prohibitive to office-based procedures. It’s also a Pret-ty, Reliable, Impeccable, and Beneficial way to correct HAV deformity. Figures 22 and 23 show the pre-op and post-op x-rays and photos of a patient with an IM angle of 22 degrees. PM

References 1 Maffulli N, Easley M. Minimally Invasive Surgery of the Foot and Ankle 2011: 97. 2 Isham S. The Reverdin-Isham procedure for HAV: Clin Pod Med Surg 1991;8: 81-94.


Dr. Peacock has been in private prac-tice for 18 years in Whiteville, NC. He was traditionally trained in a podiatric surgical residency.He is an assistant professor in the AAFAS-Academy of

Ambulatory Foot and Ankle Surgery and is a diplomate of the American Board of Po-diatric Surgery. Dr Peacock has an interest in expanding the scope and acceptance of MIS foot surgery in the podiatric medical community. He believes that MIS procedures can be used as a valuable part of a traditional foot surgeon’s arsenal of tools.


Figure 22: Pre-op and post-op 12 weeks PRIB performed on IM of 22.

Figure 23: Pre-op and post-op photos 12 weeks PRIB performed on IM angle 22.

the prib procedure - podiatry m · reputable reverdin-isham and bosch procedures led to this...

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